Laserfiche WebLink
9Asl - J '+s rt T. M#+ 4."A 4 i <br />� ¢ m .. ✓ � �.�,,,.,. z< n�t ..fir. 1 .«c.,, s.a <br />Ajr n• <br />e 't' L°' r <br />r� c q-3to .� <br />r <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />- 35 N. ChcroMe.,C.. <br />� : (n <br />STATE -AGENCY <br />�R <br />STATE <br />eS <br />! <br />. Ud i <br />STATE OF CALIFORNIA <br />Pe5°JR <br />C <br />�r ° <br />, <br />✓ BOX <br />`TOINDICATECORPORATION F7 INDIVIDUAL O PARTNERSHIP D,LOCAL-AGENCY COUNTY -AGENCY E-1STATE-AGENCY FEDERAL -AGENCY <br />STATE WATER RESOURCES CONTROL BOARD <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />3 FARM 4 PROCESSOR 5 OTHER <br />RESERVATION <br />OR TRUST LANDSlea <br />F. <br />- x� <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />SUPVISOR - DISTRICT CODE - OPTIONAL <br />i <br />MARK ONLY 1 NEW PERMIT '' <br />3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY <br />CLOSED SITE <br />}, <br />FORM A(5 -9t) FOR0033A-5 <br />ONE ITEM 2 INTERIA)`PERMIT <br />4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE' <br />f <br />= <br />I. FACILITY/SITE INFORMATION &,ADDRESS - (MUST BE COMPLETED) <br />D8 R FACILITY NAME - - <br />NAMEOF <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS. NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />1 <br />OPERATOR <br />r� c q-3to .� <br />r <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />- 35 N. ChcroMe.,C.. <br />� : (n <br />STATE -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />. Ud i <br />CA <br />c :meq() <br />()q <br />✓ BOX <br />`TOINDICATECORPORATION F7 INDIVIDUAL O PARTNERSHIP D,LOCAL-AGENCY COUNTY -AGENCY E-1STATE-AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P A I D. # (optional) <br />3 FARM 4 PROCESSOR 5 OTHER <br />RESERVATION <br />OR TRUST LANDSlea <br />F. <br />- x� <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS. NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />1 <br />DAYS: NAME (LAST, FIRST)„ -.�l j. <br />jy( -� .�V <br />r� c q-3to .� <br />r <br />NIG TS: NAMEtLAB . ST).PHONE WITHAREACODE <br />N40101m.NNAMEILAST,FI � <br />��"` 7 am <br />.. <br />E AVlarcCODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />_ie Va.�::., <br />CARE OF 'FAFDDRESS INF`ORRMATION <br />CARE,OF ADDRESS INFORMATION <br />i <br />MAILINGOR-STREETADDRESS <br />✓ box to indicate INDIVIDUAL <br />MAILING OR §TREE$ <br />a t Fes-'- _vvovrd <br />✓ box to indicate0 INDIVIDUAL <br />[]C AGENCY <br />STATE -AGENCY <br />.. t�NY <br />ZIP CODE <br />CORPORATION PARTNERSHIP <br />CO1W -*NCY <br />0 FEDERAL -AGENCY <br />CITY NAME41ATE <br />q. <br />Al� 7 <br />ZIP CODE <br />r <br />r. <br />PHONE 4 WITH A)iEAk'ODE <br />P� <br />-,- A#101UNITY# JURISDICTION# FACILITY It <br />Ill. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER ^( �' <br />CARE OF 'FAFDDRESS INF`ORRMATION <br />MAILINGOR-STREETADDRESS <br />✓ box to indicate INDIVIDUAL <br />`LOCALAGENCY = STATE -AGENCY <br />a t Fes-'- _vvovrd <br />CORPORATION PARTNERSHIP <br />I� COUNTY -AGENCY;, 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />P.��HOMMNE # WITI-F REA CODE <br />A10. A rd <br />q. <br />Al� 7 <br />, <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />i- TY (TK) HQ 4 4 y 1� c t <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY ..'MUST BE COMPLETED) _ IDENTIFY THE METHOD(S) USED <br />'• ✓ box to indicate jJ 1 SELF-INSURED [] 2 GUARANTEE C] 3 INSURANCE <br />1— 5 LETTEROFCREDIT ] 6 EXEMPTION 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal, notification and billing will be sent to the tank owner unless box I or II is checked. Y <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LECdAL NOTIFICATIONS AND BILLING: L U. rvr M. FD <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P€RJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY YEAR <br />Al� 7 <br />r <br />r. <br />LOCAL AGENCY USE ONLY <br />�. <br />-,- A#101UNITY# JURISDICTION# FACILITY It <br />LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL <br />SUPVISOR - DISTRICT CODE - OPTIONAL <br />THi$ FORM MUST BE ACCOMPANIED BY.AT LEAST (1) OR MORE PERMIT APPLICATION • FORM B, UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY, w. <br />FORM A(5 -9t) FOR0033A-5 <br />Y �+# <br />